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R. N. Sharobiem et al.
Cementoblastoma
• Clinical features
– Symptomatic hard expansion in the premolar-molar region—mandible 75%.
About 50% involve the rst permanent molar.
– Hamartomatous proliferation of cementoblasts forming disorganized cemen-
tum around the apical half of a tooth root.
– May be locally aggressive causing cortical erosion, displacement of teeth, and
inltration.
• Radiographic features
– Spherical, radiopaque mass encompassing and replacing the apical half of
tooth root.
• Histopathologic features
– Sheets of cementum-like material in continuity with the tooth root, which is
usually resorbed and replaced by this cementum.
• Treatment and prognosis
– Treatment is removal of the tooth with associated lesion. Lesion is normally
encapsulated and separates easily from surrounding bone. Does not recur if
lesion is completely removed.
Further Reading
1. August M, Faquin W, Troulis M, Kaban L.Clear cell odontogenic carcinoma: evaluation of
reported cases. J Oral Maxillofac Surg. 2003;61(5):580–6. Epub 2003/05/06.
2. Barker BF. Odontogenic myxoma. Semin Diagn Pathol. 1999;16(4):297–301. Epub
1999/12/10.
3. Barnes L, Eveson JW, Reichart P, etal., editors. World Health Organization classication of
tumours: pathology and genetics of head and neck tumours. Lyon: IARC Press; 2005.
4. Benn A, Altini M.Dentigerous cysts of inammatory origin. A clinicopathologic study. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;81(2):203–9. Epub 1996/02/01.
5. Brannon RB. The odontogenic keratocyst. A clinicopathologic study of 312 cases. Part
I.Clinical features. Oral Surg Oral Med Oral Pathol. 1976;42(1):54–72. Epub 1976/07/01.
6. Brannon RB, Goode RK, Eversole LR, Carr RF.The central granular cell odontogenic tumor:
report of 5 new cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94(5):614–21.
Epub 2002/11/09.
7. Brannon RB, Fowler CB, Carpenter WM, Corio RL.Cementoblastoma: an innocuous neoplasm? A clinicopathologic study of 44 cases and review of the literature with special emphasis on recurrence. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93(3):311–20.
Epub 2002/04/02.
8. Buchner A. Peripheral odontogenic broma. Report of 5 cases. J Craniomaxillofac Surg.
1989;17(3):134–8.
25 Odontogenic Cysts andTumors
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9. Buchner A.The central (intraosseous) calcifying odontogenic cyst: an analysis of 215 cases. J
Oral Maxillofac Surg. 1991;49(4):330–9. Epub 1991/04/01.
10. Carlson ER, Marx RE. The ameloblastoma: primary, curative surgical management. J Oral
Maxillofac Surg. 2006;64(3):484–94. Epub 2006/02/21.
11. Chen Y, Li TJ, Gao Y, Yu SF. Ameloblastic broma and related lesions: a clinicopathologic study with reference to their nature and interrelationship. J Oral Pathol Med.
2005;34(10):588–95. Epub 2005/10/06.
12. Cohen DM, Bhattacharyya I.Ameloblastic broma, ameloblastic bro-odontoma, and odontoma. Oral Maxillofac Surg Clin North Am. 2004;16(3):375–84. Epub 2007/12/20.
13. Crowley TE, Kaugars GE, Gunsolley JC. Odontogenic keratocysts: a clinical and histologic comparison of the parakeratin and orthokeratin variants. J Oral Maxillofac Surg.
1992;50(1):22–6. Epub 1992/01/01.
14. Daniels JS.Central odontogenic broma of mandible: a case report and review of the literature.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;98(3):295–300. Epub 2004/09/10.
15. Ebert CS Jr, Dubin MG, Hart CF, Chalian AA, Shockley WW.Clear cell odontogenic carcinoma: a comprehensive analysis of treatment strategies. Head Neck. 2005;27(6):536–42. Epub
2005/03/18.
16. Eliasson AH, Moser RJ III, Tenholder MF.Diagnosis and treatment of metastatic ameloblastoma. South Med J. 1989;82(9):1165–8. Epub 1989/09/01.
17. Gardner AF.The odontogenic cyst as a potential carcinoma: a clinicopathologic appraisal. J
Am Dent Assoc. 1969;78(4):746–55. Epub 1969/04/01
18. Gardner DG. The mixed odontogenic tumors. Oral Surg Oral Med Oral Pathol.
1984;58(2):166–8. Epub 1984/08/01.
19. Gardner DG. Central odontogenic broma current concepts. J Oral Pathol Med.
1996;25(10):556–61. Epub 1996/11/01.
20. Goldenberg D, Sciubba J, Koch W, Tufano RP.Malignant odontogenic tumors: a 22-year experience. Laryngoscope. 2004;114(10):1770–4. Epub 2004/09/30.
21. Gorlin RJ. Nevoid basal cell carcinoma (Gorlin) syndrome. Genet Med. 2004;6(6):530–9.
Epub 2004/11/17.
22. Gorlin RJ, Pindborg JJ, Odont, Clausen FP, Vickers RA.The calcifying odontogenic cyst—a
possible analogue of the cutaneous calcifying epithelioma of Malherbe. An analysis of fteen
cases. Oral Surg Oral Med Oral Pathol. 1962;15:1235–43. Epub 1962/10/01.
23. Kaffe I, Naor H, Buchner A.Clinical and radiological features of odontogenic myxoma of the
jaws. Dentomaxillofac Radiol. 1997;26(5):299–303. Epub 1998/03/03.
24. Kaplan I, Gal G, Anavi Y, Manor R, Calderon S.Glandular odontogenic cyst: treatment and
recurrence. J Oral Maxillofac Surg. 2005;63(4):435–41. Epub 2005/03/25.
25. Kaugars GE, Miller ME, Abbey LM. Odontomas. Oral Surg Oral Med Oral Pathol.
1989;67(2):172–6. Epub 1989/02/01.
26. Kobayashi K, Murakami R, Fujii T, Hirano A.Malignant transformation of ameloblastic broma
to ameloblastic brosarcoma: case report and review of the literature. J Craniomaxillofac Surg.
2005;33(5):352–5. Epub 2005/09/01.
27. Marx RE, Stern D.Oral and maxillofacial pathology: a rationale for diagnosis and treatment.
2nd ed. Hanover Park: Quintessence; 2012.
28. Morgan TA, Burton CC, Qian F.A retrospective review of treatment of the odontogenic keratocyst. J Oral Maxillofac Surg. 2005;63(5):635–9. Epub 2005/05/11.
29. Mosqueda-Taylor A, Carlos-Bregni R, Ramirez-Amador V, Palma-Guzman JM, EsquivelBonilla D, Hernandez-Rojase LA. Odontoameloblastoma. clinico-pathologic study of three
cases and critical review of the literature. Oral Oncol. 2002;38(8):800–5. Epub 2003/02/07.
30. Motamedi MH, Talesh KT. Management of extensive dentigerous cysts. Br Dent
J. 2005;198(4):203–6. Epub 2005/02/26.
31. Neville BW.Oral and maxillofacial pathology. 3rd ed. St. Louis: Saunders/Elsevier; 2009.
p.968, xvi.
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32. Noffke C, Raubenheimer EJ.The glandular odontogenic cyst: clinical and radiological features;
review of the literature and report of nine cases. Dentomaxillofac Radiol. 2002;31(6):333–8.
Epub 2002/11/09.
33. Owens BM, Schuman NJ, Mincer HH, Turner JE, Oliver FM.Dental odontomas: a retrospective study of 104 cases. J Clin Pediatr Dent. 1997;21(3):261–4. Epub 1997/04/01.
34. Philipsen HP, Reichart PA.Squamous odontogenic tumor (SOT): a benign neoplasm of the
periodontium. A review of 36 reported cases. J Clin Periodontol. 1996;23(10):922–6.
35. Philipsen HP, Reichart PA, Unicystic ameloblastoma. A review of 193 cases from the literature. Oral Oncol. 1998;34(5):317–25.
36. Philipsen HP, Reichart PA, Nikai H, Takata T, Kudo Y.Peripheral ameloblastoma: biological prole based on 160 cases from the literature. Oral Oncol. 2001;37(1):17–27. Epub
2000/12/20.
37. Philipsen HP, Reichart PA, Zhang KH, Nikai H, Yu QX.Adenomatoid odontogenic tumor:
biologic prole based on 499 cases. J Oral Pathol Med. 1991;20(4):149–58. Epub 1991/04/01.
38. Philipsen HP, Reichart PA, Praetorius F. Mixed odontogenic tumours and odontomas.
Considerations on interrelationship. Review of the literature and presentation of 134 new cases
of odontomas. Oral Oncol. 1997;33(2):86–99.
39. Philipsen HP, Reichart PA.Calcifying epithelial odontogenic tumour: biological prole based
on 181 cases from the literature. Oral Oncol. 2000;36(1):17–26. Epub 2000/07/13.
40. Pindborg JJ. A calcifying epithelial odontogenic tumor. Cancer. 1958;11(4):838–43. Epub
1958/07/01.
41. Poulson TC, Greer RO Jr. Adenomatoid odontogenic tumor: clinicopathologic and ultrastructural concepts. J Oral Maxillofac Surg. 1983;41(12):818–24. Epub 1983/12/01.
42. Reichart PA, Philipsen HP, Sonner S.Ameloblastoma: biological prole of 3677 cases. Eur J
Cancer B Oral Oncol. 1995;31B(2):86–99. Epub 1995/03/01.
43. Robinson L, Martinez MG.Unicystic ameloblastoma: a prognostically distinct entity. Cancer.
1977;40(5):2278–85. Epub 1977/11/01.
44. Sampson DE, Pogrel MA.Management of mandibular ameloblastoma: the clinical basis for
a treatment algorithm. J Oral Maxillofac Surg. 1999;57(9):1074–7, discussion 1078–9. Epub
1999/09/14.
45. Scheer M, Koch AM, Drebber U, Kubler AC.Primary intraosseous carcinoma of the jaws
arising from an odontogenic cyst–a case report. J Craniomaxillofac Surg. 2004;32(3):166–9.
Epub 2004/04/29.
46. Shear M.Developmental odontogenic cysts. An update. J Oral Pathol Med. 1994;23(1):1–11.
Epub 1994/01/01.
47. Shear M. The aggressive nature of the odontogenic keratocyst: is it a benign cystic neoplasm? Part 1. Clinical and early experimental evidence of aggressive behaviour. Oral Oncol.
2002;38(3):219–26. Epub 2002/04/30.
48. Slootweg PJ, Muller H.Malignant ameloblastoma or ameloblastic carcinoma. Oral Surg Oral
Med Oral Pathol. 1984;57(2):168–76. Epub 1984/02/01.
49. Vickers RA, Gorlin RJ.Ameloblastoma: delineation of early histopathologic features of neoplasia. Cancer. 1970;26(3):699–710. Epub 1970/09/01.
50. White DK, Chen SY, Hartman KS, Miller AS, Gomez LF. Central granular-cell tumor of
the jaws (the so-call granular-cell ameloblastic broma). Oral Surg Oral Med Oral Pathol.
1978;45(3):396–405. Epub 1978/03/01.
51. Wright JM.The odontogenic keratocyst: orthokeratinized variant. Oral Surg Oral Med Oral
Pathol. 1981;51(6):609–18. Epub 1981/06/01.
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1982;40(8):513–7. Epub 1982/08/01.
R. N. Sharobiem et al.
Part VI
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Laryngology
Chapter 26
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Deep Neck Space Infections
AhmedSalamaAbdelmeguid andC.KwangSung
Pearls
• In the parapharyngeal space, the prestyloid compartment contains the internal
maxillary artery, maxillary nerve, deep lobe of the parotid, and adipose tissue,
and the post-styloid compartment contains the carotid artery, internal jugular
vein, sympathetic chain, and cranial nerves IX, X, XI, and XII
• Lemierre’s syndrome is internal jugular vein (IJV) thrombophlebitis from phar-
yngitis typically due to Fusobacterium necrophorum.
Anatomy
Fascia oftheNeck
• Supercial cervical fascia
– Envelops platysma and muscles of facial expression
– Incorporates the supercial musculoaponeurotic system (SMAS)
– Extends from zygoma to the clavicles
A. S. Abdelmeguid
Department of Otolaryngology Head and Neck Surgery, Mansoura University Hospital,
Mansoura, Egypt
C. K. Sung (*)
Department of Otolaryngology- Head and Neck Surgery, Stanford University School of
Medicine, Stanford, CA, USA
e-mail: kwang.sung@stanford.edu
© Springer Nature Switzerland AG 2023
F. Y. Lin, Z. M. Patel (eds.), ENT Board Prep,
https://doi.org/10.1007/978-3-031-26048-3_26
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• Potential space between supercial and deep cervical fascia
– Contains adipose tissue, nerves, and blood vessels (anterior and external jugu-
lar veins)
• Deep cervical fascia
– Supercial (investing) layer:
Envelops parotid, submandibular gland, sternocleidomastoid, and trapezius
Extends from nuchal line, ligamentum nuahcae of cervical vertebrae, mastoid, and mandible to the clavicles
– Middle (visceral) layer:
Muscular division: envelops the infrahyoid strap muscles
Visceral division: envelops the buccinator, pharyngeal constrictor muscles,
thyroid, larynx, trachea, and esophagus, and forms pre-tracheal fascia
• Contributes the buccopharyngeal fascia posterior to the esophagus, and
pretrahceal fascia that overlies the trachea
• Forms buccopharyngeal and pterygomandibular raphe
– Deep layer (prevertebral fascia):
Prevertebral layer—ensheaths the paraspinous muscles and cervical vertebrae. Skull base to coccyx
Alar layer—lies between prevertebral and visceral layer of middle cervical
fascia. Skull base to T2
A. S. Abdelmeguid and C. K. Sung
Deep Neck Spaces
The neck spaces can be organized into groups by location: suprahyoid neck (peritonsillar, submandibular, parapharyngeal, masticator, buccal, and parotid spaces),
infrahyoid neck (anterior visceral), and the length of the neck (retropharyngeal,
danger, prevertebral, and carotid spaces).
• Peritonsillar space
– Loose connective tissue between capsule of the palatine tonsil and the supe-
rior constrictor muscle
– May connect to parapharyngeal and retropharyngeal spaces
• Submandibular space
– Mylohyoid muscle divides the submandibular space into the superior sublin-
gual compartment and the inferior submaxillary compartment. Both spaces
communicate around the posterior edge of mylohyoid muscle.
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– Tooth apices anterior to the second molar lie superior to the mylohyoid and
involve the sublingual compartment when odontogenic infections occur
– Second and third molars affect the submaxillary compartment
• Parapharyngeal space
– Inverted pyramid extending from skull base down to the hyoid
– Prestyloid compartment—contains internal maxillary artery, maxillary nerve,
deep lobe of the parotid, and adipose tissue
– Post-styloid compartment—contains carotid artery, internal jugular vein,
sympathetic chain, and cranial nerves IX, X, XI, and XII
– The carotid space travels through the parapharyngeal space en route to
mediastinum.
– Lateral spread of infection will communicate with the masticator space, infe-
rior spread reaches the submandibular space and posteromedial extension will
reach the retropharyneal space.
• Masticator space
– Lies between masseter and medial pterygoid
– Divided into the masseteric space between the mandibular ramus and maseter
muscle; and the pterygoid space between the mandibular ramus and pterygoid muscles
– Contains masseter, temporalis, medial and lateral pterygoids, ramus of the man-
dible, divisions of the mandibular nerve (V3), and the internal maxillary artery
– Infections typically from posterior molars
485
Present with severe trismus, sore throat, dysphagia
• Buccal space
– Between the buccopharyngeal fascia and the skin of the cheek
– Contains buccal fat pad, the parotid duct, and the facial artery
• Parotid space
– Formed by the supercial layer of the deep cervical fascia ensheathing the
parotid gland.
– Contains facial nerve, external carotid artery, retromandibular vein, auriculo-
temporal nerve, and supercial temporal artery
– The fascia adheres tightly to the gland laterally making it difcult to differen-
tiate abscess from cellulitis.
– Infection can spread medially to the prestyloid parapharyngeal space
• Temporal space
– Enclosed by the squamous temporal bone medially and the supercial tempo-
ralis fascia laterally.
– The temporalis muscle divide the space into supercial and deep.
– Contains the internal maxillary artery and the third division of the trigeminal
nerve (V3)
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• Anterior visceral space
– Enclosed by the visceral division of the middle layer of the deep cervical
fascia anterior to the trachea
– Extends from hyoid to superior mediastinum
– Infections caused by traumatic perforation of anterior esophagus
• Retropharyngeal space
– Between the visceral division (buccopharyngeal) of the middle layer and the
alar fascia of the deep layer
– Extends from skull base to the mediastinum at the tracheal bifurcation
– The space is fused down the midline—abscesses are unilateral and primarily
seen in children (infection of nodes of Rouviere)
• Danger space
– Posterior to retropharyngeal space between alar and prevertebral fascia
– Extends from skull base to diaphragm
– High tendency for rapid inferior spread of infection to the posterior mediasti-
num through loose areolar tissue
– Contains the cervical sympathetic chain
• Prevertebral space
– Between the prevertebral fascia and the vertebral bodies
– Extends from skull base to coccyx
– Minimal longitudinal extension of abscess due to dense areolar tissue and
brous attachments
– Infection of this space is usually direct extension of infection from vertebrae
(e.g., Pott’s abscess) or penetrating injury
A. S. Abdelmeguid and C. K. Sung
• Carotid space
– Within the carotid sheath
– Contains carotid artery, internal jugular vein, vagus nerve, deep cervical
lymph nodes, and sympathetic bers
Diagnostic Imaging
• Computed tomography (CT) scan with intravenous contrast is mainstay for neck
infections
• Magnetic resonance imaging (MRI) better for assessing intracranial extension
and vascular complications
• Ultrasound is often preferred for pediatric population
– More accurate than CT scan in differentiating a drainable abscess from cellulitis
– Cross-sectional imaging preferred for presurgical anatomic localization and
planning
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Microbiology
• Commonly polymicrobial from oropharyngeal ora or odontogenic source:
– Aerobes: Strep (viridans beta-hemolytic [pyogenes]), Staph (aureus, epider-
midis), Neisseria, Klebsiella, and Haemophilus
– Anaerobes: Bacteroides, Peptostreptococcus, Peptococcus, Fusobacterium,
Eikenella, and Veionella
• Antibiotics
– Empiric therapy with a penicillin in combination with a beta-lactamase
inhibitor (e.g., amoxicillin or ticarcillin with clavulanic acid) or a betalactamase- resistant penicillin (e.g., cefoxitin, cefuroxime, imipenem, or
meropenem)
– +/− antibiotic effective for anaerobes (e.g., clindamycin or metronidazole)
– After surgical drainage, postoperative intravenous antibiotics ahould be con-
tinued until the patient is afebrile for 48h, then continue on oral antibiotic for
additional 2 weeks
Surgical Management
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• Needle aspiration with 16 or 18 gauge needle for small abscesses
• Transoral incision and drainage—peritonsillar or retropharyngeal abscesses
• Transcervical incision and drainage
– Secure airway with awake ber-optic intubation or tracheostomy
– Pre-auricular parotid incision—parotid and temporal spaces
– Horizontal neck incision—masticator, parapharyngeal, pterygoid, subman-
dibular, prevertebral, retropharyngeal, and carotid spaces
– Submental incision—submandibular space
• In case of granulomatous disease like tuberculosis or atypical mycobacterial
infections; medical management, excisional biopsy, or needle aspiration is preferred over incisional drainage to avoid persistent draining sinus tract.
Complications ofNeck Space Infections
• Ludwig’s angina
– Rapidly spreading, rmly indurated cellulitis that originates intraorally
– Presentation: edema within sublingual, submandibular, or submental space
displaces tongue superiorly and posteriorly causing airway obstruction
– Treatment: awake ber-optic intubation or tracheostomy, broad-spectrum
antibiotics, submental incision, and drainage
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A. S. Abdelmeguid and C. K. Sung
• Lemierre’s syndrome
– Internal jugular vein (IJV) thrombophlebitis from pharyngitis
– Typically due to F. necrophorum
– Presentation: spiking fevers, engorged optic disks, increased intracranial pres-
sure, swelling and tenderness at angle of mandible, sternocleidomastoid tenderness, septic pulmonary emboli
– Treatment: IV antibiotics, anticoagulation is controversial, possible exci-
sion of IJV
– Retrograde spread can result in potentially fetal cavernous sinus thrombosis
• Carotid artery pseudoaneurysm or rupture
– Presentation: pulsatile neck mass
– Sentinel hemorrhage from mouth or nose, protracted course, neck hematoma,
cranial nerve palsies, Horner’s syndrome, and hemodynamic collapse
• Mediastinitis
– Caused by descent of infection from neck
– Increasing chest pain, dyspnea, and widened mediastinum on chest X-ray
– Mortality rate 30–40%
• Necrotizing cervical fasciitis
– Fulminant infection that spreads along fascial planes and causes extensive
necrosis
– Occurs in immunocompromised patients, especially poorly controlled
diabetics
– Polymicrobial and odontogenic—Strep pyogenes and Clostridium perfrin-
gens, MRSA, mixed aerobic and anaerobic ora
– Presentation: rapidly progressive cellulitis, pitting neck edema with orange-
peel appearance, subcutaneous crepitus
– CT scan shows tissue gas accumulation in >50%
– Treatment: critical care with treatment of immunocompromising condition,
broad-spectrum antibiotics, surgical drainage, and frequent debridement
Further Reading
1. Hegde AN, Mohan S, Pandya A, Shah GV. Imaging in infections of the head and neck.
Neuroimaging Clin N Am. 2012;22(4):727–54.
2. Megwalu UC, Shin EJ.Chapter 22. Parapharyngeal space neoplasms & deep neck space infections. In: Lalwani AK, editor. Current diagnosis & treatment in otolaryngology—head & neck
surgery. 3rd ed. NewYork: McGraw-Hill; 2012.
3. Oliver ER, Gillespie MB.Chapter 14. Deep neck space infections. In: Cummings CW, editor.
Otolaryngology: head & neck surgery. 5th ed. Philadelphia: Mosby Elsevier; 2010.
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